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Optimizing Collateral CrossingThe Experts Live Workshop 2014Session 3AN INITIATION TO RETROGRADE TECHNIQUES25 Sept 2014, 15:05 - 15:20Prof Georgios Sianos, MD, PhD, FESCDepartment of Interventional Cardiology, AHEPA University Hospital, Thessaloniki , Greece

Collaterals in RCA occlusion

Pathways and Functional Significance of the Coronary Collateral Circulation David C Levin, Circ 1974;50:831-837

Collaterals in LAD occlusionPathways and Functional Significance of the Coronary Collateral Circulation David C Levin, Circ 1974;50:831-837

Collateral Connections RAO Caudal Projection

SeptalSeptal-SeptalEpicardial- DgEpicardial-ApicalConus-Septal

Epi (OM to Dg or Dg to Dg)Yamane TCT 2014

Collateral Connection Grades in Septal ChannelsCC 0 : no visible connection

CC 1: thread-like, but visible connection, mild torturosity and mild cork-screw morphology

CC 2: clearly defined visible channel, mild torturosity and mild cork-screw morphology (Werner G. Circ 2003)

44Best characteristics of the collateral channels for retro grade wire crossing are clear visualization of the distal segment of the CTO vessel by super selective injection of the channel ( through a micro catheter ), examplified by Dr Werners connection grade 1 or 2. On the other hand, major obstacles of wire crossing are acute angulation in the channel, sharp bend, branching, cork-screw morphology, calcification and unflavorable angle either at the origin of the channel or at the confluence to the distal vessel.

Werner ClassificationAngiographic assessment by Doppler flow and pressure recordings

Werner et al, Circulation. 2003 Apr 22;107(15):1972-7

CC grade 0: no continuous connection (A: LAD to PDA-arrow, interrupted-arrowheads)CC grade 1: threadlike continuous connection (E: RCA RVB to LAD-arrowhead)CC grade 2: side branchlike connection (F: LCX and RCA marginal branch, arrows)

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Collateral Connection Size (CC)Septal pathways in 44%, epicardial in 32%CC0 14% CC1 51% CC2 35%

B

D

E

ACF

A

B

C

Werner et al. Circulation 2003;107:1972-7

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Characteristics of Collateral Channelscorkscrew-likemorphologyinelastic vessel/ stenosislength of access routedistensibilityavailabilityepicardialsignificantpotentiallylongnot dilatablelow (20%)atrialmoderateoccasionallymoderatenot dilatablelow (50%)

Corkscrew-likeInextensible/StenosisLengthApplicabilityDistensibilityEpicardialSignificantPotentialLongModest(>35%)UndilatableAtrialModerateOccasionalLongLow(60%)Dilatable

Modified from O. Katoh: CCT 2008: Retrograde for CTO CourseCharacteristics of specific channels-not all the same

Predictors of Retrograde failure

Rathore S, Katoh O, et al, Circ Cardiovasc Intervent. 2009;2:124-132

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View angle in Septal ChannelsRAO cranial view: good for checking the origin of the septal channelPitfalls continuing channel crossing with this viewNotice non-orthogonal view for the junction point

RA0 caudal view: mandatory to check the anatomy of the body and the junction point

Single view is inadequate to check the anatomyRotational angiography

View Angle and Issues in Other Channelsoptimal view anglesissuesepicardial(RV channel)RAO (cranial)APcranial for connection to LADmost tortuous channelmany side branchesinvisibility of channel during wiringshape-changeable channel by heart beating step by step approachPL channelRAO/ AP cranial (LCx-RCA, Dx-DX/LCx)LAO(cranial/ caudal) for PL channels located in anterolateral walltortuous feeding arteryatrialLAD (cranial)RAO cranialRAO/AP caudal for checking origin of feeding arterydifficult to access feeding arterymost fragile channel

CC crossing-Tip Injection

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Tip injection Epicardial Collateral

Tip injection Epicardial Collateral

CC crossing-septal surfing

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Septal Surfing

CC crossing-unexpected passage

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Septal SurfingSeptal surfing is useful for saving timeTry to slide the wire through gently, avoid buckling, avoid loops, follow with the micro-catheterDo not persist on a specific pathwayThe wire must move quickly with changing directions towards the orientation of the target vesselThe wire tip shaping is less acute bending compared to the targeted collateral crossing after tip injectionTapered wires should not be used for SSInvisible channels are sometimes crossed with septal surfing.

Tip InjectionTip injection (with rotational angiogram) is useful to maximize chance of channel crossing.isolating channelrevealing channel anatomyestimating possibility of crossingCheck of blood back-flow is mandatory to avoid channel injury and confirm connection with recipient artery prior to tip injection.As long as channel anatomy is revealed with tip injection, double/triple wire technique is helpful.

Epicardial vs Septal CrossingEpicardial Directed Higher need for MC support to negotiate tortuosityHigher need for tip injectionsSeptalOften more random (septal surfing)Tortuosity responds less well to MC supportTip injection if failure of septal surfing

Collateral Connection size and continuity (CC class)Tortuosity/branching of the channelAngle of take-off from the donor arteryCollateral take-on from the distal cupDonor artery proximal from the take-off of the CCDiseased/TortousRelation of the CC insertion site to the distal cup

Parameters to be considered for CC selection

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Collateral Connection size and continuity (CC class)Tortuosity/branching of the channelAngle of take-off from the donor arteryCollateral take-on from the distal cupDonor artery proximal from the take-off of the CCDiseased/TortousRelation of the CC insertion site to the distal cup

Parameters to be considered for CC selection

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Corkscrew appearance: scientific approachO. Katoh: CCT 2008: Retrograde for CTO Course

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CC Tortuosity/branchingWhat is visible is not necessary crossable and visa versa Failure to cross this branch

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CC TortuositySeptal surfing crossing of a more proximal septal channel

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CC tortuosity-ischemia at the territory of the occluded artery

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Collateral Connection size and continuity (CC class)Tortuosity/branching of the channelAngle of take-off from the donor arteryCollateral take-on from the distal cupDonor artery proximal from the take-off of the CCDiseased/TortousRelation of the CC insertion site to the distal cup

Parameters to be considered for CC selection

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CC take-off

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Acute angle at origin/destinationAcute angle (>90) at A or B is a negative factor for channel crossing.Dissection/ rupture is rarely caused by wire/ catheter.For negotiating acute curve at origin (A/B), double lumen microcatheres (Twinpass, Crusade are useful.

AB

Collateral Connection size and continuity (CC class)Tortuosity/branching of the channelAngle of take-off from the donor arteryCollateral take-on from the distal cupDonor artery proximal from the take-off of the CCDiseased/TortousRelation of the CC insertion site to the distal cup

Parameters to be considered for CC selection

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Donor artery and CC selection

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Donor artery and CC selection

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Collateral Connection size and continuity (CC class)Tortuosity/branching of the channelAngle of take-off from the donor arteryCollateral take-on from the distal cupDonor artery proximal from the take-off of the CCDiseased/TortousRelation of the CC insertion site to the distal cupParameters to be considered for CC selection

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Relation of the CC insertion site to the distal cup

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Relation of the CC insertion site to the distal cupWire entrapment

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Channel crossing wire selection Polymer wires (Fielder FC / Whisper) were the first to be used for channel crossing but were related with high incidence of collateral injuries.Metal ball tip hydrophilic wires are more effective and safer. Sion is first choice wire for channel crossing instead of polymer jacket wire (Fielder FC, Whisper, etc).

Tapered polymer jacket wires (XTR) became the choice for very thin and very tourtous collaterals during targeted channel crossing

Composite core technologyAddressing the channel tortousity

Composite Core technology Anti kinking structure Higher torque performance with W coreTip loadXT-A = 1.0g XT-R = 0.6g

W-Coil structure

SLIP-COAT Coating 170mm0.36mm(0.014)30mm20mmstraighttaperComposite core0.26mm(0.010)

PTFE Coating

Compatible for retrogradeapproach ; Length190cm

*SLIP-COAT is a trademark of Angiotech BioCoatings Corp. in the U.S. and/or other countries.Soft Polymeric Tappering Jacket Guide WiresFielder XT-R, Fielder XT-A

Collateral Crossing Wires

+ Tortuosity/Size -Modified J. Spratt

Potential Sequence for Collateral CrossingSION

SION Black / FFC

XRTHydrophilic ball tipPolymericTapered

Bend used for septal accessBend used to facilitate septal crossingTip shaping for Collateral CrossingIn targeted crossing of very tortuous and thing channels a very sharp and short tip bending might be necessary

Retrograde: Collateral approachAttemptCatheter used for GW support(multiple selection)No. of GW: 1.8

Collateral cross by GW, 77.1% (370/480)Multicenter Japanese Registry (2012)

Japanese Multicenter Registry Evaluating the Retrograde Approach for Chronic Coronary Total Occlusion(801 patients treated in 28 Japanese centers between January 2009 and December 2010,Corsair use increased from 36% to 95.3% from 2009 to 2010)Tsuchikane et al, Catheterization and Cardiovascular Interventions 82:E654E661 (2013)Procedural success rate 84.8 % (retrograde success 71.2%)Clinical success rate 83.8% (retrograde success70.3%)

All (n:801) 2009 (n:378)2010 (n:423)Collateral channel cross by guidewire 82.3% (659) 80.4% (304) 83.9% (355) Successfully crossed collateral channel Septal 63.0% (415/659) 68.4% (208/304) 58.3% (207/355)Epicardial 32.6% (215/659) 27.6% (84/304) 36.9% (131/355)Bypass graft 4.4% (29/659) 3.9% (12/304) 4.8% (17/355)

Procedure time (min) 195.184.5 203.384.4 187.984.1 (p:0.024)

Multivariate analysis identified age 65 years or more and lesion calcification as unfavorable factors and the use of a channel dilator as a favorable factor for retrograde procedural success.

MALE, 63 Y, SA CLASS III Radial AL 1.5 6FrFemoral EBU 3.5 7 Fr Gaia First

Septal Surfing FC

Corsair/ Finecross failed to cross despite anchoring in D1

Different S crossing with surfing also failed to crossReturn to first S and balloon dilatationMini Trek 1.25

Prox LAD spasmMC crossing

LAD compromised

Balloon predilatation and stent implantation in prox LAD

MC advancement underneath the stent struts

Final result

Solving MC crossing problems

Choose Guiding catheters with good backup support

Change the failing MC (Corsair/Finecross)

Ballooning by small balloon with low pressure

Balloon anchoring

Others (another retro channel, ante approach)

SummaryGood guiding catheter supportCareful evaluation of the angiogram in multiple projections or rotational angiographyDonor arteryCC for angle of take-off, size, tortouosity, branching, angle of insertion at the distal vessel, its relation with the distal cup In septal channels try surfing firstSlide the wire through gently, avoid buckling, avoid loops, follow with the microcatheterIn case of failure continue with tip injectionsIn epicardial channels tip injection is mandatoryUse composite core SION wire as first choice followed by polymeric/tapered wires according to the anatomy of the channelReshape the wire tip once you are in the channel if necessaryOptimize parameters for micro-cather crossingMost injuries are un-harmful but be prepared for coil embolization if nessecaryRemember what is visible is not necessary crossable and visa versa

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